Will Insurance Cover Breast Reconstruction, or is it Cosmetic?

Breast Reconstruction is not considered cosmetic surgery. While there is a cosmetic or aesthetic component to breast reconstruction, reconstructive surgery for cancer, trauma, or congenital abnormalities (birth defects) is not considered cosmetic. Under the Women’s Health & Cancer Act of 1998, all group health plans, insurance companies, and HMO’s that offer mastectomy coverage must also provide coverage for reconstructive surgery after mastectomy. This coverage includes:

Reconstruction of the breast removed by mastectomy

Reconstruction of other breast to produce a symmetrical appearance including breast augmentation, breast lifting, or breast reduction

Replacement and maintenance of breast implants used for reconstruction

Reconstruction of the nipple and areolar as well as areolar tattooing

Treatment of physical complications related to the surgery

This law sets a federal standard so women can obtain breast reconstruction following mastectomy even if they live in states that do not require insurance companies to provide this coverage.

In most cases, reconstruction to correct a lumpectomy deformity will also be covered by insurance. If your insurance carrier denies approval to have the type of reconstructive surgery you want, with a specific surgeon of your choice, you can appeal. It is important to check with your insurance carrier to find a surgeon that meets your reconstruction needs. It’s nice to know that the law is on your side.